本文選題：腰間盤突出癥　切入點(diǎn)：椎間孔鏡　出處：《大連醫(yī)科大學(xué)》2017年碩士論文　論文類型：學(xué)位論文

【摘要】：背景:隨著社會(huì)的進(jìn)步、醫(yī)學(xué)科學(xué)的快速發(fā)展,縮小創(chuàng)傷、加快術(shù)后康復(fù)、減短術(shù)后患者臥床時(shí)間等越來(lái)越受到人們的關(guān)注。隨著目前脊柱外科領(lǐng)域腰椎病和頸椎病患病率的逐年增加,單純的保守治療已經(jīng)很難達(dá)到治療目的。自開(kāi)放手術(shù)開(kāi)創(chuàng)以來(lái),經(jīng)過(guò)約半個(gè)世紀(jì)的不斷發(fā)展,已經(jīng)非常成熟,但是傳統(tǒng)開(kāi)放性手術(shù)手術(shù)并發(fā)癥(創(chuàng)傷大、出血多、術(shù)后疼痛嚴(yán)重、術(shù)中腰背部的肌肉、軟組織廣泛剝離等)也越來(lái)越受到各方面的廣泛關(guān)注,這些并發(fā)癥造成的軟組織損傷導(dǎo)致的患者術(shù)后慢性腰痛常常影響治療效果。隨著其他外科微創(chuàng)手術(shù)的出現(xiàn),微創(chuàng)手術(shù)因其創(chuàng)傷小、術(shù)中出血少、對(duì)椎旁軟組織損傷小、術(shù)后疼痛輕、恢復(fù)快等特點(diǎn)得到大家的青睞,脊柱外科的大夫也想利用脊柱微創(chuàng)技術(shù)解決脊柱問(wèn)題。早期,醫(yī)生在開(kāi)放手術(shù)的基礎(chǔ)上發(fā)明了小開(kāi)窗,其優(yōu)勢(shì)較開(kāi)放手術(shù)已經(jīng)非常明顯,但是隨著其他外科顯微技術(shù)的快速發(fā)展,小開(kāi)窗逐漸滿足不了要求。隨著內(nèi)鏡系統(tǒng)在其他外科的普及,脊柱內(nèi)鏡手術(shù)也開(kāi)始慢慢出現(xiàn)。后路顯微內(nèi)鏡下行腰椎間盤切除術(shù)(MED)的出現(xiàn),為脊柱內(nèi)鏡作出了巨大貢獻(xiàn),可以說(shuō)具有劃時(shí)代的意義,它的臨床療效在一段時(shí)間內(nèi)得到了人們的認(rèn)可。隨著相關(guān)顯微技術(shù)技術(shù)及顯微器械的進(jìn)一步高速發(fā)展,更為"微創(chuàng)"的椎間孔鏡技術(shù)(將工作套管直接植入椎管內(nèi),在內(nèi)鏡直視下行髓核摘除及神經(jīng)根減壓,PELD)逐漸進(jìn)入我們的視野。我們發(fā)現(xiàn)通過(guò)椎間孔鏡直視下行髓核摘除、神經(jīng)根減壓(椎間孔鏡技術(shù)),具有創(chuàng)傷更小、更安全、恢復(fù)更快等特點(diǎn),較間盤鏡手術(shù),椎間孔鏡手術(shù)的認(rèn)可度更高。目前隨著椎間孔鏡技術(shù)的快速發(fā)展,逐漸出現(xiàn)多種手術(shù)入路,其中大家較為常用的是后路椎板間入路及側(cè)后方椎間孔入路,這兩種手術(shù)入路逐漸成熟并逐漸在各大小醫(yī)院得到普及,目前國(guó)內(nèi)并不缺乏這兩種手術(shù)入路的研究報(bào)道,但是卻無(wú)系統(tǒng)及完整的比較,包括這兩種術(shù)式的優(yōu)缺點(diǎn)及這兩種手術(shù)入路的最佳適應(yīng)癥。本文將研究、比較這兩種手術(shù)入路,得出這兩種術(shù)式的最佳適應(yīng)癥及在L5-S1節(jié)段時(shí)兩種術(shù)式的優(yōu)缺點(diǎn)。目的:研究椎間孔鏡經(jīng)椎間孔入路(transforaminal,TF)和椎板間入路(interlaminar,IL),得出這兩種手術(shù)入路的最佳適應(yīng)癥,同時(shí)比較在L5-S1節(jié)段行這兩種術(shù)式的患者,得出在L5-S1節(jié)段行兩種術(shù)式的優(yōu)缺點(diǎn)。方法:收集大連市中心醫(yī)院自2015年至2016年間行椎間孔鏡手術(shù)包括經(jīng)椎板間(interlaminar,IL)入路及椎間孔(transforaminal,TF)入路的患者,統(tǒng)計(jì)這兩種手術(shù)入路的基本手術(shù)數(shù)據(jù)包括穿刺次數(shù)、手術(shù)時(shí)間、透視次數(shù)、出血量、患者術(shù)后臥床時(shí)間、手術(shù)至出院時(shí)間、并發(fā)癥、術(shù)前術(shù)后改善情況(術(shù)后當(dāng)日、出院時(shí)VAS評(píng)分及術(shù)后六月Oswestry功能障礙指數(shù))、術(shù)后6月MacNab評(píng)分等等,得出這兩種術(shù)式的最佳適應(yīng)癥。比較2015年至2016年間大連市中心醫(yī)院所有L5-S1節(jié)段行PETD和PEID手術(shù)的患者的手術(shù)基本資料,得出在L5-S1節(jié)段時(shí),這兩種術(shù)式的優(yōu)劣。結(jié)果:行PETD手術(shù)組的患者和行PEID組手術(shù)的患者的性別構(gòu)成、年齡構(gòu)成、椎間盤髓核突出類型均無(wú)明顯統(tǒng)計(jì)學(xué)差異(p0.05)。在L5-S1階段行兩種手術(shù)術(shù)式的患者,PEID組的手術(shù)時(shí)間為80±14.8min,術(shù)中C型臂透視次數(shù)平均為5.0±2次,術(shù)后臥床時(shí)間平均為為12±2h,手術(shù)至出院時(shí)間為3.0±1.8d,術(shù)中出血量約為16.8±7.1m 1;PETD組分別131±16.2min,15±6 次,12.0±1.1h,4.0±1.2d,25.6±2ml。PEID組的手術(shù)時(shí)間、術(shù)中C型臂透視次數(shù)、出血量等均明顯低于PETD組(p0.01),兩組間術(shù)后臥床時(shí)間、住院時(shí)間無(wú)統(tǒng)計(jì)學(xué)差異(p0.05)。PEID組術(shù)后3例并發(fā)神經(jīng)根痛,無(wú)復(fù)發(fā),PETD組術(shù)后并發(fā)神經(jīng)根痛4例,術(shù)后三月復(fù)發(fā)1例,行切開(kāi)手術(shù)后癥狀緩解,隨訪6月無(wú)新發(fā)陽(yáng)性癥狀;兩組間術(shù)后并發(fā)癥發(fā)生率無(wú)統(tǒng)計(jì)學(xué)差異(p0.05)。PEID組術(shù)前VAS、ODI分別為8±1.6分、(60.9±15.3)%,術(shù)后當(dāng)日、出院時(shí)、末次隨訪V AS 分別為 5.3±2.6、2.8±1.6、1.2±0.9 分;末次隨訪 ODI評(píng)分為(30.6±16.3%);PETD組術(shù)前VAS、ODI分別為7±2.5分、(60.8±20.5)%,術(shù)后當(dāng)日、出院時(shí)、末次隨訪VAS評(píng)分分別為5±2、2±1、1.3±0.8分、(32±7.6)%。兩組末次隨訪時(shí)的VAS評(píng)分和ODI均較術(shù)前明顯改善(p0.05),兩組間術(shù)前、末次隨訪時(shí)的VAS評(píng)分和ODI均無(wú)統(tǒng)計(jì)學(xué)差異(p0.05)。按照Macnab療效評(píng)定標(biāo)準(zhǔn)評(píng)定術(shù)后6月患者情況,無(wú)論行PETD術(shù)式還是在L5S1節(jié)段行PETD和PEID術(shù)式的患者,其6月后優(yōu)良率均大于90%.結(jié)論:經(jīng)皮內(nèi)鏡,無(wú)論是PEID術(shù)式還是PETD術(shù)式,其療效較開(kāi)放手術(shù)無(wú)明顯差異,但是出血少、切口小、術(shù)后恢復(fù)快、對(duì)人體損傷小等都是開(kāi)放手術(shù)不具備的優(yōu)勢(shì),經(jīng)皮內(nèi)鏡經(jīng)過(guò)一段時(shí)間的發(fā)展,將會(huì)成為以后脊柱外科手術(shù)治療的首選手術(shù)方案。就L5S1節(jié)段的腰椎間盤突出而言,需要我們結(jié)合患者自身情況、影像學(xué)資料等選擇合適的治療方案,才能取得良好的術(shù)后療效。
[Abstract]:Background: with the social progress and the rapid development of medical science, reduce trauma, accelerate the rehabilitation after operation, shorten the postoperative bed time has attracted more and more attention. With the current field of lumbar and cervical spine disease prevalence rate increased year by year, conservative treatment alone has been difficult to achieve the goal of treatment. Since the open surgery to create, through the continuous development of about half a century, has been very mature, but the traditional open surgery complications (bleeding, severe trauma, postoperative pain, waist and back muscles during operation, extensive soft tissue stripping) has attracted more and more attention in all aspects, often chronic low back pain the effect of lead to soft tissue injury caused by these complications of patients after operation. With the emergence of other minimally invasive surgery, minimally invasive surgery for its small trauma, less bleeding, injury of paraspinal soft tissue small, Postoperative pain, rapid recovery and so on by people of all ages, spinal surgery doctor wants to use the technology to solve the problem of minimally invasive spinal spine. The early invention of the small window based on open surgery doctor, it has very obvious advantages compared with open surgery, but with the rapid development of the he microsurgery technology, small window gradually can not meet the requirements. With the popularization of endoscope system in other spinal surgery, endoscopic surgery also started to appear. Descending posterior microendoscopic lumbar discectomy (MED) has made a great contribution to the spine endoscope, can be said to have epoch-making significance, its clinical effect has been recognized by the people in a time. With the further rapid development of related technology and micro micro instruments, more "transforaminal endoscopic minimally invasive" (the working cannula implanted directly into the spinal canal, in endoscopy Underwent discectomy and nerve root decompression, PELD) into our vision. We found that by transforaminal endoscopic euthyphoria discectomy and nerve root decompression (foraminal mirror), with less trauma, more safety, faster recovery etc., the operation is disc mirror, intervertebral foramen surgery recognition a higher degree. At present, with the rapid development of foraminal mirror technology, the gradual emergence of a variety of surgical approach, in which everyone is commonly used is the posterior approach and posterolateral transforaminal approach, the two gradually mature and gradually get the size of the hospital popularity at home is not the lack of research reports the two approach, but no system and complete comparison, including the advantages and disadvantages of these two kinds of operation and the two approach the best adaptation. This paper will study and compare these two approaches, the two methods of optimal Should be in and the advantages and disadvantages of two kinds of operation in the L5-S1 segment. Objective: To study the transforaminal endoscopic transforaminal (transforaminal, TF) and interlaminar approach (interlaminar, IL), obtained the best indications of these two surgical approaches, and comparison in L5-S1 segment for the two surgical patients, the advantages and disadvantages of the L5-S1 segment for two kinds of operation. Methods: We collected the Central Hospital of Dalian from 2015 to 2016 for transforaminal endoscopic surgery including interlaminar (interlaminar, IL) approach and foramen (transforaminal, TF) in patients with basic surgery statistics these two surgical approaches including the number of puncture, operation time, fluoroscopy times, bleeding volume, postoperative bed time, time to discharge, surgical complications, preoperative and postoperative improvement (postoperative day, June at discharge VAS score and postoperative Oswestry dysfunction index), postoperative June MacNab score 絳，

本文編號(hào)：1579060